Marlise Richter

'We are despised in the hospitals': sex workers' experiences of accessing health care in four African countries

Sex workers in east and southern Africa are exposed to multiple occupational health and safety risks. Detailed understanding of barriers to accessing care would optimise design of improved services for this population. In this study, trained sex workers conducted 55 in-depth interviews and 12 focus group discussions with 106 female, 26 male and 4 transgender sex workers across 6 urban sites in Kenya, Zimbabwe, Uganda and South Africa. Data were analysed thematically, following an interpretive framework. Participants cited numerous unmet health needs, including diagnosis and treatment for sexually transmitted infections and insufficient access to condoms and lubricant. Denial of treatment for injuries following physical assault or rape and general hostility from public-sector providers was common. Resources permitting, many sex workers attended private services, citing higher quality and respect for dignity and confidentiality. Sex workers in southern Africa accessed specialised sex worker clinics, reporting mostly positive experiences. Across sites, participants called for additional targeted services, but also sensitisation and training of public-sector providers. Criminalisation of sex workers and associated stigmatisation, particularly of transgender and male sex workers, hinder HIV-prevention efforts and render access to mainstream healthcare precarious. Alongside law reform, sex worker-led peer outreach work should be strengthened and calls by sex workers for additional targeted services heeded.

Human rights abuses and collective resilience among sex workers in four African countries: a qualitative study

BackgroundSex work is a criminal offence, virtually throughout Africa. This criminalisation and the intense stigma attached to the profession shapes interactions between sex workers and their clients, family, fellow community members, and societal structures such as the police and social services.MethodsWe explore the impact of violence and related human rights abuses on the lives of sex workers, and how they have responded to these conditions, as individuals and within small collectives. These analyses are based on data from 55 in-depth interviews and 12 focus group discussions with female, male and transgender sex workers in Kenya, South Africa, Uganda and Zimbabwe. Data were collected by sex worker outreach workers trained to conduct qualitative research among their peers.ResultsIn describing their experiences of unlawful arrests and detention, violence, extortion, vilification and exclusions, participants present a picture of profound exploitation and repeated human rights violations. This situation has had an extreme impact on the physical, mental and social wellbeing of this population. Overall, the article details the multiple effects of sex work criminalisation on the everyday lives of sex workers and on their social interactions and relationships. Underlying their stories, however, are narratives of resilience and resistance. Sex workers in our study draw on their own individual survival strategies and informal forms of support and very occasionally opt to seek recourse through formal channels. They generally recognize the benefits of unified actions in assisting them to counter risks in their environment and mobilise against human rights violations, but note how the fluctuant and stigmatised nature of their profession often undermines collective action.ConclusionsWhile criminal laws urgently need reform, supporting sex work self-organisation and community-building are key interim strategies for safeguarding sex workers’ human rights and improving health outcomes in these communities. If developed at sufficient scale and intensity, sex work organisations could play a critical role in reducing the present harms caused by criminalisation and stigma.

Disability grants or antiretrovirals? A quandary for people with HIV/AIDS in South Africa

According to the Department of Social Development, disability grants are available to adult South African citizens and permanent residents who are incapacitated and unable to work due to illness or disability. A number of people living with HIV/AIDS (PWAs) have accessed disability grants once they have fulfilled the criteria set down by the Department of Social Development. Current government policies entitle PWAs, a least in theory, to access antiretroviral medications. Where PWAs have been able to access antiretroviral treatment (ART) through the governments antiretroviral programme, this has led to an improvement in their health and subsequent disqualification for a disability grant. In South Africas highly unequal society, the disability grant often operates as the only source of income for poor families. This has created an untenable situation as many PWAs are forced to choose between receiving their disability grant and accessing life-saving medication. We explore the intersection of social security with access to ART and argue that it presents complex problems in the context of HIV/AIDS, and thus requires urgent debate and resolution. Potential solutions to this problem, including the provision of a basic income grant to all South Africans, are proposed.

Home self-testing for HIV: AIDS exceptionalism gone wrong

Self-tests for HIV in South Africa are currently unregulated. Gaps in law and policy have created a legal loophole where such tests could effectively be sold in supermarkets, but not in pharmacies. At the same time, South Africa lacks an effective regulating mechanism for diagnostic tests, which brings the quality and reliability of all self-tests into question. The authors argue for greater access to, and availability of, quality HIV self-tests. This strategy will encourage regular HIV testing, allay fears about stigma and confidentiality when testing in public facilities, and decrease the costs associated with traditional voluntary counselling and testing, and is likely to lead to earlier diagnosis and treatment of HIV. The South African Medical Association (SAMA) recently warned the public against using HIV self-testing kits. SAMA chairman Norman Mabasa noted that it was ‘risky’ for individuals to test themselves ‘unmonitored’ and that it might lead to devastated patients or suicide. 1-3

Female sex work and international sport events: no major changes in demand or supply of paid sex during the 2010 Soccer World Cup: a cross-sectional study

BackgroundImportant unanswered questions remain on the impact of international sporting events on the sex industry. Speculation about increased demand and supply of sex work often generates significant attention, but also additional funding for HIV programmes. This study assessed whether changes occurred in the demand and supply of paid sex during the 2010 Soccer World Cup in South Africa.MethodsTrained sex worker interviewers conducted face-to-face semi-structured interviews among consenting female sex workers during May-September 2010. Using bivariate analyses we compared supply, demand, sexual risk-taking, and police and health services contact pre-World Cup, to levels during the World Cup and after the event.ResultsNo increases were detected in indicators of sex work supply, including the proportion of sex workers newly arrived in the city (< 2.5% in each phase) or those recently entering the trade (≤ 1.5%). Similarly, demand for sex work, indicated by median number of clients (around 12 per week) and amount charged per transaction (

Exposure Ethics: Does HIV Pre‐Exposure Prophylaxis Raise Ethical Problems for the Health Care Provider and Policy Maker?

13) remained similar in the three study periods. Only a third of participants reported observing any change in the sex industry ascribed to the World Cup. Self-reported condom-use with clients remained high across all samples (> 92.4% in all phases). Health-care utilisation decreased non-significantly from the pre- to during World Cup period (62.4% to 57.0%; P = 0.075). Across all periods, about thirty percent of participants had interacted with police in the preceding month, two thirds of whom had negative interactions.ConclusionsContrary to public opinion, no major increases were detected in the demand or supply of paid sex during the World Cup. Although the study design employed was unable to select population-based samples, these findings do not support the public concern and media speculation prior to the event, but rather signal a missed opportunity for public health action. Given the media attention on sex work, future sporting events offer strategic opportunities to implement services for sex workers and their clients, especially as health service utilisation might decrease in this period.

“A Baby Was an Added Burden”: Predictors and Consequences of Unintended Pregnancies for Female Sex Workers in Mombasa, Kenya: A Mixed-Methods Study

The last few years have seen dramatic progress in the development of HIV pre-exposure prophylaxis (PrEP). These developments have been met by ethical concerns. HIV interventions are often thought to be ethically difficult. In a context which includes disagreements over human rights, controversies over testing policies, and questions about sexual morality and individual responsibility, PrEP has been seen as an ethically complex intervention. We argue that this is mistaken, and that in fact, PrEP does not raise new ethical concerns. Some of the questions posed by PrEP are not specific to HIV prophylaxis, but simply standard public health considerations about resource allocation and striking a balance between individual benefit and public good. We consider sexual disinhibition in the context of private prescriptions, and conclude that only unjustified AIDS-exceptionalism or inappropriate moralism about sex supports thinking that PrEP raises new ethical problems. This negative conclusion is significant in a context where supposed ethical concerns about PrEP have been raised, and in the context of HIV exceptionalism.

Sex Work during the 2010 FIFA World Cup: Results from a Three-Wave Cross-Sectional Survey

Introduction Female sex workers (FSW) have high rates of unintended pregnancy, sexually transmitted infections including HIV, and other adverse sexual and reproductive health outcomes. Few services for FSWs include contraception. This mixed-methods study aimed to determine the rate, predictors and consequences of unintended pregnancy among FSWs in Mombasa, Kenya. Methods A prospective cohort study of non-pregnant FSWs was conducted. Quantitative data were collected quarterly, including a structured questionnaire and testing for pregnancy and HIV. Predictors of unintended pregnancy were investigated using multivariate logistic regression. Qualitative data were gathered through focus group discussions and in-depth interviews with FSWs who became pregnant during the study, and interviews with five key informants. These data were transcribed, translated and analysed thematically. Results Four hundred women were enrolled, with 92% remaining in the cohort after one year. Fifty-seven percent reported using a modern contraceptive method (including condoms when used consistently). Over one-third (36%) of women were using condoms inconsistently without another method. Twenty-four percent had an unintended pregnancy during the study. Younger age, having an emotional partner and using traditional or no contraception, or condoms only, were independent predictors of unintended pregnancy. Women attributed pregnancy to forgetting to use contraception and being pressured not to by clients and emotional partners, as well as “bad luck”. They described numerous negative consequences of unintended pregnancy. Conclusion Modern contraceptive uptake is surprisingly low in this at-risk population, which in turn has a high rate of unintended pregnancy. The latter may result in financial hardship, social stigma, risk of abandonment, or dangerous abortion practices. FSWs face considerable barriers to the adoption of dual method contraceptive use, including low levels of control in their emotional and commercial relationships. Reproductive health services need to be incorporated into programs for sexually transmitted infections and HIV, which address the socially-determined barriers to contraceptive use.

Serious soccer, sex (work) and HIV - will South Africa be too hot to handle during the 2010 World Cup?

Background In the months leading up to the 2010 FIFA World Cup in South Africa, international media postulated that at least 40,000 foreign sex workers would enter South Africa, and that an increased HIV incidence would follow. To strengthen the evidence base of future HIV prevention and sexual health programmes during international sporting events, we monitored the supply and demand of female sex work in the weeks before, during and after the 2010 FIFA World Cup. Methodology/Principal Findings We conducted three telephonic surveys of female sex workers advertising online and in local newspapers, in the last week of May, June and July 2010. The overall response rate was 73.4% (718/978). The number of sex workers advertising online was 5.9% higher during the World Cup than before. The client turnover rate did not change significantly during (adjusted rate ratio [aRR] = 1.05; 95%CI: 0.90–1.23) or after (aRR = 1.06; 95%CI: 0.91–1.24) the World Cup. The fraction of non-South African sex workers declined during (adjusted odds ratio [aOR] = 0.50; 95%CI: 0.32–0.79) and after (aOR = 0.56; 95%CI: 0.37–0.86) the World Cup. Relatively more clients were foreign during the World Cup among sex workers advertising in the newspapers (aOR = 2.74; 95%CI: 1.37–5.48) but not among those advertising online (aOR = 1.06; 95%CI: 0.60–1.90). Self-reported condom use was high (99.0%) at baseline, and did not change during (aOR = 1.07; 95% CI: 0.16–7.30) or after (aOR = 1.13; 95% CI: 0.16–8.10) the Word Cup. Conclusions/Significance Our findings do not provide evidence for mass-immigration of foreign sex workers advertising online and in local newspapers, nor a spike in sex work or risk of HIV transmission in this subpopulation of sex workers during the World Cup. Public health programmes focusing on sex work and HIV prevention during international sporting events should be based on evidence, not media-driven sensationalism that further heightens discrimination against sex workers and increases their vulnerability.

Being pimped out - How South Africa's AIDS response fails sex workers

Soccer fever is sweeping through South African streets – be they tarred, dusty or potholed. Stadiums are being polished until they shine, road signs repainted, and dank garden sheds converted into pricy bed & breakfasts. South Africa is putting its best foot forward, and wherever panic rears its head the FIFA Local Organising Committee and politicians are doing damage control. Yet a troubling and neglected topic is sex. Indeed, with the expected influx of visitors, more sex. If the AIDS epidemic has taught us anything, it is that sex is a part of human behaviour that neither governments nor the law can control. Newspaper reports have alluded to the fact that South Africa has one of the highest HIV prevalence rates in the world and that ‘innocent’ tourists might return home with nasty HIV from Africa. 1-3 Worse still, that these ‘innocent’ tourists will consort with ‘dubious’ sex workers and find themselves languishing in overcrowded South African prisons 4 long after the last vuvuzela has announced the end of the final game. Indeed, Dutch soccer fans have been warned to bring their own condoms, as South Africa might run out; 5 the Department of Health has responded by assuring everyone that it is well prepared. 6 Recently, Britain donated a million pounds for an additional 42 million male condoms. 7